{ "hospital_name": "South Texas Rehabilitation Hospital", "last_updated_on": "2026-03-17", "version": "3.0.0", "location_name": [ "South Texas Rehabilitation Hospital" ], "hospital_address": [ "425 E Alton Gloor Blvd, Brownsville, TX 78526" ], "license_information": { "state": "TX" }, "type_2_npi": [ "1093712697" ], "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": "Room & Board - Private (One Bed) - Rehabilitation", "code_information": [ { "code": "0118", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1050, "methodology": "per diem", "median_amount": 1050, "10th_percentile": 1050, "90th_percentile": 1050, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1450, "methodology": "per diem", "median_amount": 1450, "10th_percentile": 1450, "90th_percentile": 1450, "count": "1 through 10" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Rehabilitation", "code_information": [ { "code": "0128", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 825, "methodology": "per diem", "median_amount": 825, "10th_percentile": 825, "90th_percentile": 825, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_dollar": 800, "methodology": "per diem", "median_amount": 800, "10th_percentile": 800, "90th_percentile": 800, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1450, "methodology": "per diem", "median_amount": 1450, "10th_percentile": 1450, "90th_percentile": 1450, "count": "1 through 10" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 800, "maximum": 2450 } ] }, { "description": "Room & Board - Three and Four Beds - Rehabilitation", "code_information": [ { "code": "0138", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 900, "methodology": "per diem", "median_amount": 900, "10th_percentile": 900, "90th_percentile": 900, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 1400, "methodology": "per diem", "median_amount": 1400, "10th_percentile": 1400, "90th_percentile": 1400, "count": "1 through 10" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Deluxe Private - Rehabilitation", "code_information": [ { "code": "0148", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Ward - Rehabilitation", "code_information": [ { "code": "0158", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 974.97, "methodology": "per diem", "median_amount": 974.97, "10th_percentile": 974.97, "90th_percentile": 974.97, "count": "1 through 10" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 1000, "methodology": "per diem", "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1350, "methodology": "per diem", "median_amount": 1350, "10th_percentile": 1350, "90th_percentile": 1350, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Workers' Compensation", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Other Long-term Care Products", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "No Fault", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Paradigm Specialty Networks fka AdvaNet", "plan_name": "Auto Liability", "standard_charge_dollar": 2450, "methodology": "per diem", "median_amount": 2450, "10th_percentile": 2450, "90th_percentile": 2450, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 850, "methodology": "per diem", "median_amount": 850, "10th_percentile": 850, "90th_percentile": 850, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 875, "methodology": "per diem", "median_amount": 875, "10th_percentile": 875, "90th_percentile": 875, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_dollar": 1100, "methodology": "per diem", "median_amount": 1100, "10th_percentile": 1100, "90th_percentile": 1100, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 850, "maximum": 2450 } ] }, { "description": "Room & Board - Private (One Bed) - General Classification", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Rio Grand Valley ACO", "plan_name": "Medicare Shared Savings Program (MSSP)", "standard_charge_dollar": 950, "methodology": "per diem", "median_amount": 950, "10th_percentile": 950, "90th_percentile": 950, "count": "1 through 10" } ], "minimum": 950, "maximum": 1030.1 } ] }, { "description": "Room & Board - Private (One Bed) - Other", "code_information": [ { "code": "0119", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - General Classification", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Other", "code_information": [ { "code": "0129", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Three and Four Beds - General Classification", "code_information": [ { "code": "0130", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Three and Four Beds - Other", "code_information": [ { "code": "0139", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Deluxe Private - General Classification", "code_information": [ { "code": "0140", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per 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"standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Deluxe Private - Other", "code_information": [ { "code": "0149", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": 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"90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": 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Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": 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diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Room & Board - Ward - Other", "code_information": [ { "code": "0159", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_dollar": 1030.1, "methodology": "per diem", "median_amount": 1030.1, "10th_percentile": 1030.1, "90th_percentile": 1030.1, "count": "1 through 10" } ], "minimum": 1030.1, "maximum": 1030.1 } ] }, { "description": "Subacute Care - General Classification", "code_information": [ { "code": "0190", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 300 } ] }, { "description": "Subacute Care - Level I", "code_information": [ { "code": "0191", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 297, "methodology": "per diem", "median_amount": 297, "10th_percentile": 297, "90th_percentile": 297, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 297, "methodology": "per diem", "median_amount": 297, "10th_percentile": 297, "90th_percentile": 297, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 297, "maximum": 300 } ] }, { "description": "Subacute Care - Level II", "code_information": [ { "code": "0192", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 446, "methodology": "per diem", "median_amount": 446, "10th_percentile": 446, "90th_percentile": 446, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 446, "methodology": "per diem", "median_amount": 446, "10th_percentile": 446, "90th_percentile": 446, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 446 } ] }, { "description": "Subacute Care - Level III", "code_information": [ { "code": "0193", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 744, "methodology": "per diem", "median_amount": 744, "10th_percentile": 744, "90th_percentile": 744, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 744, "methodology": "per diem", "median_amount": 744, "10th_percentile": 744, "90th_percentile": 744, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 744 } ] }, { "description": "Subacute Care - Level IV", "code_information": [ { "code": "0194", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 781, "methodology": "per diem", "median_amount": 781, "10th_percentile": 781, "90th_percentile": 781, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 781, "methodology": "per diem", "median_amount": 781, "10th_percentile": 781, "90th_percentile": 781, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_dollar": 300, "methodology": "per diem", "median_amount": 300, "10th_percentile": 300, "90th_percentile": 300, "count": "1 through 10" } ], "minimum": 300, "maximum": 781 } ] }, { "description": "Medical Rehabilitation Day Program - Half Day", "code_information": [ { "code": "0931", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Rehabilitation Day Program - Full Day", "code_information": [ { "code": "0932", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Health Insurance Prospective Payment System (HIPPS) - Inpatient Rehabilitation Facility", "code_information": [ { "code": "0024", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=63.50 and M <72.50- Tier Tier 1", "code_information": [ { "code": "B0102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stroke M >=50.50 and M <63.50- Tier None", "code_information": [ { "code": "A0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B0103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20404.98, "10th_percentile": 20404.98, "90th_percentile": 20404.98, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20404.98, "maximum": 20404.98 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24817.21, "10th_percentile": 24817.21, "90th_percentile": 24817.21, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 2087.39, "10th_percentile": 2087.39, "90th_percentile": 27148.94, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 2087.39, "maximum": 24817.21 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0104", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26040.87, "10th_percentile": 26040.87, "90th_percentile": 26040.87, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 22574.59, "10th_percentile": 22574.59, "90th_percentile": 26040.87, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22574.59, "maximum": 26040.87 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31033.57, "10th_percentile": 2327.52, "90th_percentile": 31033.57, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31033.57, "maximum": 31033.57 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 39371.07, "10th_percentile": 39371.07, "90th_percentile": 39371.07, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 39371.07, "maximum": 39371.07 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31911.49, "10th_percentile": 31911.49, "90th_percentile": 31911.49, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32562.74, "10th_percentile": 32562.74, "90th_percentile": 32562.74, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 35670.22, "10th_percentile": 32562.74, "90th_percentile": 35670.22, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31911.49, "maximum": 35670.22 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34144.84, "10th_percentile": 34144.84, "90th_percentile": 34144.84, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 35296.27, "10th_percentile": 35296.27, "90th_percentile": 35296.27, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 35296.27, "10th_percentile": 35296.27, "90th_percentile": 38112.18, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 1579.24, "10th_percentile": 1579.24, "90th_percentile": 1579.24, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1579.24, "maximum": 35296.27 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 46733.67, "10th_percentile": 46733.67, "90th_percentile": 46733.67, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 46733.67, "maximum": 46733.67 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 40530.17, "10th_percentile": 40530.17, "90th_percentile": 40530.17, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 40530.17, "maximum": 40530.17 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 36296.94, "10th_percentile": 36296.94, "90th_percentile": 36296.94, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37037.69, "10th_percentile": 37037.69, "90th_percentile": 37037.69, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37037.69, "10th_percentile": 37037.69, "90th_percentile": 40180.35, "count": "12" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 37037.69, "10th_percentile": 30826, "90th_percentile": 40180.35, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 36296.94, "maximum": 37037.69 } ] }, { "description": "Traumatic brain injury M >=73.50- Tier None", "code_information": [ { "code": "A0201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B0203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 19977.26, "10th_percentile": 19977.26, "90th_percentile": 19977.26, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19977.26, "maximum": 19977.26 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 23328.24, "10th_percentile": 23328.24, "90th_percentile": 23328.24, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23328.24, "maximum": 23328.24 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29880.67, "10th_percentile": 29880.67, "90th_percentile": 29880.67, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 29880.67, "10th_percentile": 29880.67, "90th_percentile": 29880.67, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29880.67, "maximum": 29880.67 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 1", "code_information": [ { "code": "B0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 34942.52, "10th_percentile": 34942.52, "90th_percentile": 34942.52, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34942.52, "10th_percentile": 34942.52, "90th_percentile": 34942.52, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 24033.17, "10th_percentile": 24033.17, "90th_percentile": 24033.17, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24033.17, "maximum": 34942.52 } ] }, { "description": "Traumatic brain injury M <35.50- Tier Tier 3", "code_information": [ { "code": "D0205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 31737.86, "10th_percentile": 31737.86, "90th_percentile": 31737.86, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31737.86, "10th_percentile": 31737.86, "90th_percentile": 34897.97, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31737.86, "maximum": 31737.86 } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier None", "code_information": [ { "code": "A0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic brain injury M >=65.50- Tier Tier 2", "code_information": [ { "code": "C0301", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0302", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 20769.98, "10th_percentile": 20769.98, "90th_percentile": 20769.98, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 2225.36, "10th_percentile": 2225.36, "90th_percentile": 2225.36, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 2225.36, "maximum": 20769.98 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0303", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22037.05, "10th_percentile": 22037.05, "90th_percentile": 22037.05, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 22037.05, "10th_percentile": 22037.05, "90th_percentile": 22037.05, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22037.05, "maximum": 22037.05 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24082.37, "10th_percentile": 2408.24, "90th_percentile": 26385.49, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24082.37, "maximum": 24082.37 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27814.44, "10th_percentile": 27814.44, "90th_percentile": 27814.44, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27814.44, "maximum": 27814.44 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25550.44, "10th_percentile": 25550.44, "90th_percentile": 28183.9, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25550.44, "maximum": 25550.44 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26558.63, "10th_percentile": 26558.63, "90th_percentile": 28903.27, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26558.63, "maximum": 26558.63 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 38341.74, "10th_percentile": 38341.74, "90th_percentile": 38341.74, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 38341.74, "maximum": 38341.74 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 28177.84, "10th_percentile": 28177.84, "90th_percentile": 28177.84, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28177.84, "10th_percentile": 28177.84, "90th_percentile": 28177.84, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 28177.84, "10th_percentile": 28177.84, "90th_percentile": 28177.84, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28177.84, "maximum": 28177.84 } ] }, { "description": "Traumatic spinal cord injury M >=56.50- Tier None", "code_information": [ { "code": "A0401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 79919.92, "10th_percentile": 79919.92, "90th_percentile": 79919.92, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 79919.92, "maximum": 79919.92 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 54419.98, "10th_percentile": 54419.98, "90th_percentile": 54419.98, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 54419.98, "maximum": 54419.98 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M >=53.50 and M <60.50- Tier Tier 1", "code_information": [ { "code": "B0502", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21376.39, "10th_percentile": 21376.39, "90th_percentile": 21376.39, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21376.39, "maximum": 21376.39 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 23195.96, "10th_percentile": 23195.96, "90th_percentile": 23195.96, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23195.96, "maximum": 23195.96 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23640.19, "10th_percentile": 23640.19, "90th_percentile": 23640.19, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23640.19, "maximum": 23640.19 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-traumatic spinal cord injury M <39.50- Tier None", "code_information": [ { "code": "A0505", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 32848.96, "10th_percentile": 32848.96, "90th_percentile": 32848.96, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32848.96, "maximum": 32848.96 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37732.32, "10th_percentile": 37732.32, "90th_percentile": 37732.32, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37732.32, "maximum": 37732.32 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 35646.8, "10th_percentile": 35646.8, "90th_percentile": 35646.8, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 19950.96, "10th_percentile": 19950.96, "90th_percentile": 20991.48, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19950.96, "maximum": 35646.8 } ] }, { "description": "Neurological M >=64.50- Tier None", "code_information": [ { "code": "A0601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A0602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 17081.33, "10th_percentile": 17081.33, "90th_percentile": 17081.33, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17081.33, "maximum": 17081.33 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 18940.13, "10th_percentile": 18940.13, "90th_percentile": 18940.13, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 18940.13, "10th_percentile": 18940.13, "90th_percentile": 18940.13, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 12114.19, "10th_percentile": 12114.19, "90th_percentile": 12114.19, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 12114.19, "maximum": 18940.13 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20126.8, "10th_percentile": 20126.8, "90th_percentile": 20126.8, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20126.8, "maximum": 20126.8 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23905.5, "10th_percentile": 23905.5, "90th_percentile": 23905.5, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23905.5, "maximum": 23905.5 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24361.4, "10th_percentile": 24361.4, "90th_percentile": 24361.4, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22316.84, "10th_percentile": 22316.84, "90th_percentile": 22316.84, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 22316.84, "10th_percentile": 22316.84, "90th_percentile": 22316.84, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22316.84, "maximum": 24361.4 } ] }, { "description": "Neurological M <43.50- Tier None", "code_information": [ { "code": "A0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27674.35, "10th_percentile": 27674.35, "90th_percentile": 27674.35, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25241.71, "10th_percentile": 25241.71, "90th_percentile": 25241.71, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25241.71, "maximum": 27674.35 } ] }, { "description": "Neurological M <43.50- Tier Tier 1", "code_information": [ { "code": "B0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 40044.57, "10th_percentile": 40044.57, "90th_percentile": 40044.57, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 40044.57, "10th_percentile": 40044.57, "90th_percentile": 40044.57, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 40044.57, "maximum": 40044.57 } ] }, { "description": "Neurological M <43.50- Tier Tier 2", "code_information": [ { "code": "C0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29980.36, "10th_percentile": 29980.36, "90th_percentile": 32711.66, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 29980.36, "10th_percentile": 29980.36, "90th_percentile": 29980.36, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29980.36, "maximum": 29980.36 } ] }, { "description": "Neurological M <43.50- Tier Tier 3", "code_information": [ { "code": "D0604", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27988.1, "10th_percentile": 27988.1, "90th_percentile": 27988.1, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27988.1, "10th_percentile": 27988.1, "90th_percentile": 30810.99, "count": "17" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 27988.1, "10th_percentile": 27988.1, "90th_percentile": 27988.1, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27988.1, "maximum": 27988.1 } ] }, { "description": "Fracture of lower extremity M >=61.50- Tier None", "code_information": [ { "code": "A0701", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16864.25, "10th_percentile": 16864.25, "90th_percentile": 18553.59, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16864.25, "maximum": 16864.25 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A0703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20739.43, "10th_percentile": 20739.43, "90th_percentile": 20739.43, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20739.43, "maximum": 20739.43 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 22447.08, "10th_percentile": 22447.08, "90th_percentile": 22447.08, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 22447.08, "maximum": 22447.08 } ] }, { "description": "Fracture of lower extremity M <41.50- Tier None", "code_information": [ { "code": "A0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25334.97, "10th_percentile": 25334.97, "90th_percentile": 28065.77, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 25261.32, "10th_percentile": 25261.32, "90th_percentile": 25261.32, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25261.32, "maximum": 25334.97 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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- Tier Tier 2", "code_information": [ { "code": "C0704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28948.05, "10th_percentile": 28948.05, "90th_percentile": 32339.64, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28948.05, "maximum": 28948.05 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26873.66, "10th_percentile": 26873.66, "90th_percentile": 26873.66, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27422.1, "10th_percentile": 27422.1, "90th_percentile": 27422.1, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 27422.1, "10th_percentile": 27422.1, "90th_percentile": 27422.1, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26873.66, "maximum": 27422.1 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16213.03, "10th_percentile": 16213.03, "90th_percentile": 16213.03, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16213.03, "maximum": 16213.03 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 16832.1, "10th_percentile": 16832.1, "90th_percentile": 16832.1, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16832.1, "maximum": 16832.1 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 18046.1, "10th_percentile": 18046.1, "90th_percentile": 18046.1, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 18046.1, "10th_percentile": 18046.1, "90th_percentile": 18046.1, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 18046.1, "maximum": 18046.1 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20879.19, "10th_percentile": 20879.19, "90th_percentile": 20879.19, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20879.19, "maximum": 20879.19 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20218.45, "10th_percentile": 5443.43, "90th_percentile": 22284.41, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 19586.72, "10th_percentile": 19586.72, "90th_percentile": 19586.72, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19586.72, "maximum": 20218.45 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 2786.21, "10th_percentile": 2786.21, "90th_percentile": 22615.92, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 2786.21, "maximum": 2786.21 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26595.61, "10th_percentile": 26595.61, "90th_percentile": 26595.61, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26595.61, "maximum": 26595.61 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24247.99, "10th_percentile": 24247.99, "90th_percentile": 27755.46, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24247.99, "maximum": 24247.99 } ] }, { "description": "Other orthopedic M >=63.50- Tier None", "code_information": [ { "code": "A0901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16438.15, "10th_percentile": 16438.15, "90th_percentile": 16438.15, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16438.15, "maximum": 16438.15 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 16923.88, "10th_percentile": 16923.88, "90th_percentile": 16923.88, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16923.88, "maximum": 16923.88 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 19629.94, "10th_percentile": 19629.94, "90th_percentile": 19629.94, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 19629.94, "10th_percentile": 19629.94, "90th_percentile": 19629.94, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19629.94, "maximum": 19629.94 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D0903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21454.97, "10th_percentile": 21454.97, "90th_percentile": 23552.12, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 21454.97, "10th_percentile": 21454.97, "90th_percentile": 21454.97, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21454.97, "maximum": 21454.97 } ] }, { "description": "Other orthopedic M <44.5- Tier None", "code_information": [ { "code": "A0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23050.78, "10th_percentile": 23050.78, "90th_percentile": 23050.78, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23521.2, "10th_percentile": 23521.2, "90th_percentile": 23521.2, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23521.2, "10th_percentile": 23521.2, "90th_percentile": 25874.18, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23050.78, "maximum": 23521.2 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 1", "code_information": [ { "code": "B0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34436.01, "10th_percentile": 34436.01, "90th_percentile": 39639.07, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34436.01, "maximum": 34436.01 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 2", "code_information": [ { "code": "C0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 30024.63, "10th_percentile": 30024.63, "90th_percentile": 30024.63, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 27581.29, "10th_percentile": 27581.29, "90th_percentile": 27581.29, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27581.29, "maximum": 30024.63 } ] }, { "description": "Other orthopedic M <44.5- Tier Tier 3", "code_information": [ { "code": "D0904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25193.86, "10th_percentile": 25193.86, "90th_percentile": 25193.86, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25708.02, "10th_percentile": 25708.02, "90th_percentile": 25708.02, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25708.02, "10th_percentile": 25708.02, "90th_percentile": 28361.98, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 25708.02, "10th_percentile": 25708.02, "90th_percentile": 28361.98, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25193.86, "maximum": 25708.02 } ] }, { "description": "Amputation lower extremity M >=64.50- Tier None", "code_information": [ { "code": "A1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation lower extremity M <47.50- Tier None", "code_information": [ { "code": "A1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37000.7, "10th_percentile": 37000.7, "90th_percentile": 41670.21, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37000.7, "maximum": 37000.7 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 2", "code_information": [ { "code": "C1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34624.68, "10th_percentile": 34624.68, "90th_percentile": 34624.68, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34624.68, "maximum": 34624.68 } ] }, { "description": "Amputation lower extremity M <47.50- Tier Tier 3", "code_information": [ { "code": "D1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27952.73, "10th_percentile": 27952.73, "90th_percentile": 27952.73, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 6470.13, "10th_percentile": 6470.13, "90th_percentile": 27952.73, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 27952.73, "10th_percentile": 24366.8, "90th_percentile": 27952.73, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 6470.13, "maximum": 27952.73 } ] }, { "description": "Amputation non-lower extremity M >=58.50- Tier None", "code_information": [ { "code": "A1101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "B1203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23868.52, "10th_percentile": 23868.52, "90th_percentile": 23868.52, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23868.52, "maximum": 23868.52 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance 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Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D1304", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A1305", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D1401", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1402", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16519.09, "10th_percentile": 16519.09, "90th_percentile": 16519.09, "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": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 18694.65, "10th_percentile": 18694.65, "90th_percentile": 18694.65, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16519.09, "maximum": 18694.65 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28158.55, "10th_percentile": 28158.55, "90th_percentile": 28158.55, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28158.55, "maximum": 28158.55 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20625.27, "10th_percentile": 20625.27, "90th_percentile": 22596.49, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 20625.27, "10th_percentile": 19141.84, "90th_percentile": 22596.49, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20625.27, "maximum": 20625.27 } ] }, { "description": "Cardiac M <45.50- Tier None", "code_information": [ { "code": "A1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23254.28, "10th_percentile": 23254.28, "90th_percentile": 25927.07, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 4152.55, "10th_percentile": 4152.55, "90th_percentile": 5813.57, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 4152.55, "maximum": 23254.28 } ] }, { "description": "Cardiac M <45.50- Tier Tier 1", "code_information": [ { "code": "B1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 37851.24, "10th_percentile": 37851.24, "90th_percentile": 37851.24, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 34503.54, "10th_percentile": 34503.54, "90th_percentile": 34503.54, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 34503.54, "10th_percentile": 34503.54, "90th_percentile": 34503.54, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 34503.54, "maximum": 37851.24 } ] }, { "description": "Cardiac M <45.50- Tier Tier 2", "code_information": [ { "code": "C1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27180.91, "10th_percentile": 27180.91, "90th_percentile": 27180.91, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27180.91, "10th_percentile": 27180.91, "90th_percentile": 27180.91, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27180.91, "maximum": 27180.91 } ] }, { "description": "Cardiac M <45.50- Tier Tier 3", "code_information": [ { "code": "D1404", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25272.26, "10th_percentile": 25272.26, "90th_percentile": 28194.48, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 19492.76, "10th_percentile": 19492.76, "90th_percentile": 25272.26, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 19492.76, "maximum": 25272.26 } ] }, { "description": "Pulmonary M >=68.50- Tier None", "code_information": [ { "code": "A1501", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 20339.73, "10th_percentile": 20339.73, "90th_percentile": 20339.73, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20339.73, "maximum": 20339.73 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary M >=45.50 and M <56.50- Tier Tier 1", "code_information": [ { "code": "B1503", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23968.21, "10th_percentile": 23968.21, "90th_percentile": 23968.21, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23968.21, "maximum": 23968.21 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary M <45.50- Tier Tier 3", "code_information": [ { "code": "D1504", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 27915.74, "10th_percentile": 27915.74, "90th_percentile": 31100.15, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27915.74, "10th_percentile": 27915.74, "90th_percentile": 27915.74, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27915.74, "maximum": 27915.74 } ] }, { "description": "Pain syndrome M >=65.50- Tier None", "code_information": [ { "code": "A1601", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=50.50 and M <57.50- Tier None", "code_information": [ { "code": "A1702", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 17446.34, "10th_percentile": 17446.34, "90th_percentile": 17446.34, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17446.34, "maximum": 17446.34 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1703", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major multiple trauma without brain or spinal cord injury M >=36.50 and M <41.50- Tier None", "code_information": [ { "code": "A1704", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 15250.48, "10th_percentile": 15250.48, "90th_percentile": 15250.48, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 15250.48, "maximum": 15250.48 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 28471.3, "10th_percentile": 28471.3, "90th_percentile": 28471.3, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28471.3, "maximum": 28471.3 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 27534.66, "10th_percentile": 27534.66, "90th_percentile": 27534.66, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 27534.66, "maximum": 27534.66 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 32771.77, "10th_percentile": 32771.77, "90th_percentile": 32771.77, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 32771.77, "maximum": 32771.77 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 30350.19, "10th_percentile": 30350.19, "90th_percentile": 30350.19, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 30350.19, "maximum": 30350.19 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 20636.52, "10th_percentile": 20636.52, "90th_percentile": 20636.52, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 20636.52, "maximum": 20636.52 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1805", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 1", "code_information": [ { "code": "B1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D1806", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A1901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A1904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 16073.14, "10th_percentile": 16073.14, "90th_percentile": 16073.14, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 16073.14, "maximum": 16073.14 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 23665.91, "10th_percentile": 23665.91, "90th_percentile": 23665.91, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23665.91, "maximum": 23665.91 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 3", "code_information": [ { "code": "D2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 17658.59, "10th_percentile": 17658.59, "90th_percentile": 17658.59, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 17658.59, "10th_percentile": 17658.59, "90th_percentile": 17658.59, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 17658.59, "maximum": 17658.59 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 6083.59, "10th_percentile": 6083.59, "90th_percentile": 6083.59, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 6083.59, "maximum": 6083.59 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28340.24, "10th_percentile": 28340.24, "90th_percentile": 28340.24, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28340.24, "maximum": 28340.24 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 M <55.50- Tier Tier 3", "code_information": [ { "code": "D2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 21146.24, "10th_percentile": 21146.24, "90th_percentile": 22783.38, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 21146.24, "10th_percentile": 21146.24, "90th_percentile": 22783.38, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 21146.24, "10th_percentile": 21146.24, "90th_percentile": 21146.24, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 21146.24, "maximum": 21146.24 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 23013.08, "10th_percentile": 23013.08, "90th_percentile": 25436.92, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 23013.08, "maximum": 23013.08 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33884.48, "10th_percentile": 33884.48, "90th_percentile": 37257.06, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 33884.48, "maximum": 33884.48 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 29878.29, "10th_percentile": 27065.13, "90th_percentile": 29878.29, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29878.29, "maximum": 29878.29 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 25283.52, "10th_percentile": 25283.52, "90th_percentile": 25283.52, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25283.52, "10th_percentile": 25283.52, "90th_percentile": 27787.19, "count": "26" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 25283.52, "10th_percentile": 25283.52, "90th_percentile": 25283.52, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25283.52, "maximum": 25283.52 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 24257.64, "10th_percentile": 24257.64, "90th_percentile": 24257.64, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 24257.64, "10th_percentile": 24257.64, "90th_percentile": 24257.64, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 24257.64, "10th_percentile": 24257.64, "90th_percentile": 24257.64, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 24257.64, "maximum": 24257.64 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 35715.94, "10th_percentile": 35715.94, "90th_percentile": 35715.94, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 35715.94, "maximum": 35715.94 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28528.38, "10th_percentile": 28528.38, "90th_percentile": 31274.7, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 28528.38, "maximum": 28528.38 } ] }, { "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data 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": 26650.28, "10th_percentile": 26650.28, "90th_percentile": 26650.28, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26650.28, "10th_percentile": 26650.28, "90th_percentile": 29084.87, "count": "11" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 26650.28, "10th_percentile": 4164.11, "90th_percentile": 26650.28, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26650.28, "maximum": 26650.28 } ] }, { "description": "Burns M >=52.50- Tier None", "code_information": [ { "code": "A2101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A5001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 None", "code_information": [ { "code": "A5102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 104, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Evaluation or Re-evaluation", "code_information": [ { "code": "0424", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 80, "methodology": "fee schedule", "median_amount": 80, "10th_percentile": 80, "90th_percentile": 80, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 62, "maximum": 150 } ] }, { "description": "Physical Therapy - General Classification", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 60, "maximum": 120 } ] }, { "description": "Therapeutic exercises", "code_information": [ { "code": "97110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 135, "count": "26" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 135, "count": "26" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 135, "count": "26" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 135, "count": "26" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 67.5, "10th_percentile": 67.5, "90th_percentile": 135, "count": "26" }, { "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 56, "10th_percentile": 28, "90th_percentile": 84, "count": "104" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 53.2, "10th_percentile": 26.6, "90th_percentile": 79.8, "count": "125" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 53.2, "maximum": 120 } ] }, { "description": "Occupational Therapy - Evaluation or Reevaluation", "code_information": [ { "code": "0434", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 80, "methodology": "fee schedule", "median_amount": 80, "10th_percentile": 80, "90th_percentile": 80, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 62, "maximum": 150 } ] }, { "description": "Speech Therapy - Language Pathology - Evaluation or Reevaluation", "code_information": [ { "code": "0444", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 80, "methodology": "fee schedule", "median_amount": 80, "10th_percentile": 80, "90th_percentile": 80, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 62, "methodology": "fee schedule", "median_amount": 62, "10th_percentile": 62, "90th_percentile": 62, "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 62, "maximum": 150 } ] }, { "description": "Occupational Therapy - General Classification", "code_information": [ { "code": "0430", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 60, "maximum": 120 } ] }, { "description": "Inpatient Renal Dialysis - General Classification", "code_information": [ { "code": "0800", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "description": "Inpatient Renal Dialysis - Hemodialysis", "code_information": [ { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "description": "Inpatient Renal Dialysis - Peritoneal Dialysis (Non-CAPD)", "code_information": [ { "code": "0802", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD)", "code_information": [ { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "description": "Inpatient Renal Dialysis - Continuous Cycling Peritoneal Dialysis (CCPD)", "code_information": [ { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "description": "Inpatient Renal Dialysis - Other", "code_information": [ { "code": "0809", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 500, "methodology": "per diem", "median_amount": 500, "10th_percentile": 500, "90th_percentile": 500, "count": "1 through 10" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 50, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 500, "maximum": 600 } ] }, { "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": "Ct abd & pelv w/contrast", "code_information": [ { "code": "74177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted e&m service", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caregiver traing 1st 30 min", "code_information": [ { "code": "97550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prothrombin time", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of natriuretic peptide", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood culture for bacteria", "code_information": [ { "code": "87040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs sf/low 25", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sars-cov-2 covid-19 amp prb", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood gases any combination", "code_information": [ { "code": "82803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "C-reactive protein", "code_information": [ { "code": "86140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "C diff amplified probe", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of vancomycin", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay thyroid stim hormone", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phosphorus", "code_information": [ { "code": "84100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture othr specimn aerobic", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of prealbumin", "code_information": [ { "code": "84134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29126", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdom complete", "code_information": [ { "code": "76700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93971", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of pelvis", "code_information": [ { "code": "72170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of calcium", "code_information": [ { "code": "82330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lower extremity study", "code_information": [ { "code": "93926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine culture/colony count", "code_information": [ { "code": "87086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 1 or 2", "code_information": [ { "code": "73560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback 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"payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urinalysis auto w/scope", "code_information": [ { "code": "81001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee 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"count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue 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"plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", 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"standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam abdomen 1 view", "code_information": [ { "code": "74018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "1st hosp ip/obs high 75", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ferritin", "code_information": [ { "code": "82728", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sensory integration", "code_information": [ { "code": "97533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Community/work reintegration", "code_information": [ { "code": "97537", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 3+ musc", "code_information": [ { "code": "20561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 1 or 2 musc", "code_information": [ { "code": "20560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood gases w/o2 saturation", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+iontphrsis ea 15", "code_information": [ { "code": "97033", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Paraffin bath therapy", "code_information": [ { "code": "97018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Complete cbc automated", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 & w/dye", "code_information": [ { "code": "70470", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Renal function panel", "code_information": [ { "code": "80069", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 120 } ] }, { "description": "Vent mgmt inpat init day", "code_information": [ { "code": "94002", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing rbc antigens", "code_information": [ { "code": "86905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp virus 12-25 targets", "code_information": [ { "code": "87633", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Procalcitonin (pct)", "code_information": [ { "code": "84145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of magnesium", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs moderate 35", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthetic traing 1st enc", "code_information": [ { "code": "97761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mechanical traction therapy", "code_information": [ { "code": "97012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "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 & w/dye", "code_information": [ { "code": "72158", "type": "HCPCS" } ], "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": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - General Classification", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 42, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Chemistry", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_percentage": 42, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - General Classification", "code_information": [ { "code": "0410", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 120, "maximum": 120 } ] }, { "description": "Physical Therapy - Visit Charge", "code_information": [ { "code": "0421", "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" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 60, "maximum": 95 } ] }, { "description": "Speech Therapy - Language Pathology - General Classification", "code_information": [ { "code": "0440", "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" }, { "payer_name": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Cigna Health and Life Insurance Company", "plan_name": "Commercial", "standard_charge_dollar": 85, "methodology": "fee schedule", "median_amount": 85, "10th_percentile": 85, "90th_percentile": 85, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) EPO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "Commercial-Exchange (ACA) HMO", "standard_charge_dollar": 60, "methodology": "fee schedule", "median_amount": 60, "10th_percentile": 60, "90th_percentile": 60, "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": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Commercial (All Payer)", "standard_charge_dollar": 95, "methodology": "fee schedule", "median_amount": 95, "10th_percentile": 95, "90th_percentile": 95, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 60, "maximum": 120 } ] }, { "description": "Therapeutic activities", "code_information": [ { "code": "97530", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "15" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 67.5, "count": "15" }, { "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.49, "10th_percentile": 33.49, "90th_percentile": 66.98, "count": "44" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 31.82, "10th_percentile": 31.82, "90th_percentile": 127.28, "count": "74" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 31.82, "maximum": 120 } ] }, { "description": "Neuromuscular reeducation", "code_information": [ { "code": "97112", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 33.75, "10th_percentile": 33.75, "90th_percentile": 33.75, "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.15, "10th_percentile": 31.15, "90th_percentile": 31.15, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 29.59, "10th_percentile": 29.59, "90th_percentile": 59.18, "count": "19" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 29.59, "maximum": 120 } ] }, { "description": "Gait training therapy", "code_information": [ { "code": "97116", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 31.22, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 31.22, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 31.22, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 31.22, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.22, "10th_percentile": 31.22, "90th_percentile": 31.22, "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 28, "10th_percentile": 28, "90th_percentile": 28, "count": "17" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 26.6, "10th_percentile": 26.6, "90th_percentile": 53.2, "count": "26" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 26.6, "maximum": 120 } ] }, { "description": "Speech/hearing therapy", "code_information": [ { "code": "92507", "type": "HCPCS" } ], "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": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 70, "maximum": 120 } ] }, { "description": "Manual therapy 1/> regions", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 26.44, "10th_percentile": 26.44, "90th_percentile": 52.88, "count": "69" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 31.8, "10th_percentile": 31.8, "90th_percentile": 31.8, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 25.12, "10th_percentile": 25.12, "90th_percentile": 50.24, "count": "73" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25.12, "maximum": 120 } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 95.34, "10th_percentile": 95.34, "90th_percentile": 95.34, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 116.19, "10th_percentile": 116.19, "90th_percentile": 116.19, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90.57, "maximum": 150 } ] }, { "description": "Ther ivntj ea addl 15 min", "code_information": [ { "code": "97130", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aquatic therapy/exercises", "code_information": [ { "code": "97113", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 155, "10th_percentile": 155, "90th_percentile": 155, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 155, "10th_percentile": 155, "90th_percentile": 155, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 155, "10th_percentile": 155, "90th_percentile": 155, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 155, "10th_percentile": 155, "90th_percentile": 155, "count": "1 through 10" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 155, "10th_percentile": 155, "90th_percentile": 155, "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 155 } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "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": "HealthSpring Life & Health Insurance Company aka Cigna HealthSpring", "plan_name": "Medicare Advantage", "standard_charge_dollar": 70, "methodology": "fee schedule", "median_amount": 70, "10th_percentile": 70, "90th_percentile": 70, "count": "1 through 10" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 97.79, "10th_percentile": 97.79, "90th_percentile": 97.79, "count": "1 through 10" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 92.9, "10th_percentile": 92.9, "90th_percentile": 92.9, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 92.9, "maximum": 150 } ] }, { "description": "Ther ivntj 1st 15 min", "code_information": [ { "code": "97129", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 120 } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90.57, "maximum": 150 } ] }, { "description": "Hemodialysis one evaluation", "code_information": [ { "code": "90935", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 120 } ] }, { "description": "Unlisted special svc px/rprt", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "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": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 120, "maximum": 150 } ] }, { "description": "Pt eval high complex 45 min", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare-Medicaid Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "HEALTHSELECT", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Workforce Commission (TWC)", "plan_name": "Vocational Rehabilitation Services", "standard_charge_percentage": 60, "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": "Molina Healthcare of Texas", "plan_name": "CHIP RSA", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP Perinatal", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "CHIP MCO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "STAR Kids", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "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": "Celtic Insurance Company", "plan_name": "PPO", "standard_charge_dollar": 120, "methodology": "fee schedule", "median_amount": 120, "10th_percentile": 120, "90th_percentile": 120, "count": "1 through 10" }, { "payer_name": "Texas Independence Health Plan (TIHP)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Insurance Company Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Austin Resolutions' Client Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Association Health Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Self-funded Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Health Maintenance Organization Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "AlterNet Medical Services", "plan_name": "Group Health and Wellness Plans", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Workers' Compensation", "standard_charge_percentage": 126, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Automobile Liability", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Corvel Healthcare Corporation", "plan_name": "Accident & Health", "standard_charge_percentage": 80, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Texas Health and Human Services", "plan_name": "Comprehensive Rehabilitation Services (CRS) program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "CHIP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": " National Advantage Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Passport to Healthcare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Meritain/Meritain Shared Administrative Services", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Joint Claims Administration", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Signature Administrators", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Indemnity Plans with Network Incentives", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Student Health", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Aetna Choice POS II", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Managed Choice POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Open Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "Elect Choice", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "QPOS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "EPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Aetna Network Services", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "WellMed", "plan_name": "Medicare Advantage", "standard_charge_percentage": 95, "methodology": "fee schedule", "median_amount": 90.57, "10th_percentile": 90.57, "90th_percentile": 90.57, "count": "1 through 10" }, { "payer_name": "Devoted Health", "plan_name": "MA SNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA PPO (EPO and SNP)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Devoted Health", "plan_name": "MA HMO (including POS)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90.57, "maximum": 150 } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "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": "Superior HealthPlan", "plan_name": "MMP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options Plus", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Molina Medicare Options", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Health Insurance Marketplace (ACA)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "MA-PD Plan", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Superior HealthPlan", "plan_name": "Medicare Advantage Plan (MA Plan)", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Traditional Indemnity", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "PPO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Advantage HMO", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage POS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Texas", "plan_name": "Blue Essentials", "standard_charge_percentage": 108, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Molina Healthcare of Texas", "plan_name": "Star+PLUS Medicare